2. Vulvar Aphthous Ulcers in Children with COVID-19: A case series

BACKGROUND: Vulvar aphthous ulcers are defined by acute onset of painful genital lesions that are associated with viral illness. They classically present in non-sexually active girls and are diagnosed once other more common cause of genital ulcerations, including STIs or autoimmune bullous diseases, have been excluded. Previous reports of vulvar aphthous ulcers associated with COVID-19 have described treatment of the symptoms with either local or systemic corticosteroids. This case series illustrates the ability to manage these patients conservatively resulting in complete and spontaneous resolution of the ulcers. CASE: Four females, ages ranging from 10 to 21, presented to the emergency department for vulvar pain. Each patient was diagnosed with vulvar aphthous ulcers based on physical examination. All four patients were diagnosed with COVID-19 with rapid antigen testing. With directed counseling, each patient and their family were instructed on a regimen of acetaminophen, sitz baths, and voiding in the bath. Topical analgesics such as lidocaine gel were not administered and steroids were not prescribed. All four patients were able to manage their symptoms at home and did not require admission to the hospital. All patients experienced spontaneous and complete restoration of anatomy in 1-2 weeks. COMMENTS: The novel coronavirus pandemic caused by SARS-CoV02 has resulted in considerable morbidity and mortality. While immunocompromised hosts are more susceptible to complications of COVID-19, patients with intact immune systems may also experience distressing viral related symptoms. The pathogenesis of these ulcers has been hypothesized to be a result of non-specific inflammatory response to a viral systemic illness resulting in blistering of the mucosal genital surfaces It has been proposed that the ulcers are secondary to a cytokine storm that occurs in SARS-CoV-2 infections. Elevated cytokines, including TNF-α, result in neutrophil chemotaxis to mucosal tissue and subsequent ulceration of the tissue. Previous case studies discussing vulvar aphthous ulcers associated with COVID-19 all required hospitalization for pain control and/or urinary retention and treatment with steroids. Hospitalization can be a traumatic experience for both child and adolescent patients as well as their family. The added isolation and precautions required for treating COVID positive patients can have a further psychological impact. Through directive counseling, all patients in our case series were able to avoid hospitalization and supportive care of the genital lesions in the outpatient setting was sufficient.